Confidentiality

Information and decisions are likely to involve several or even many other people; moreover, the multiple informal relationships (and gossip) in the communal atmosphere should not mislead the doctor into being more relaxed about confidentiality than would be expected in a hospital. What is learned in a professional relationship is confidential information, to be shared with others with permission and with discretion. The only other person likely to be in a privileged position, that is with whom a matter can be discussed without formal consent, is another doctor. Beyond this it is a matter of good faith and common sense; thus what it is reasonable to discuss with a school nurse, teacher, lecturer, or college counsellor will be different in different suituations, and in any event the young person (and parents, if involved) should be kept informed.

The strong peer relationships characterizing normal adolescence can mean that a young person is confiding more in another boy or girl than with parents, teachers, or counsellor; occasionally they might want them to accompany them to a session, and the psychiatrist's concern should be not only the patient's privacy but that of anyone else the young person might want to disclose something about. Another complication is being asked to 'keep a secret', by or about a pupil or student. The clinician caught off guard may unwisely offer unconditional confidentiality, only to be informed that the student has accumulated a cache of medication for a future overdose, deals in drugs, is pregnant, or is planning to abscond. Nor is it unknown for a member of staff to say that the doctor 'must not tell anyone' (because of a promise the teacher has made to a pupil) but nevertheless is expected to act decisively in some way on this information. In all such cases the clinician will be helped not only by clarity about professional guidelines on confidentiality, but by familiarity with the different professional roles, responsibilities, and lines of accountability within a school. The consultative task includes clarifying who is involved with what, and who needs to know about it. Diplomatic skills are also useful.

A central issue here is the young person's right to confidentiality when the matter in question has 'public' consequences; for example, the threat of suicide or of an aggressive threat towards an individual. It is reasonable to anticipate a degree of shared information on a need-to-know basis. A troubled child may well be relieved to know that the other people looking after him will hear about his distress; indeed, he may have assumed that sensible adults will inevitably be discussing him discreetly, and be relieved at the honesty of the practitioner who says so. When working in a school it is important to remember that views about how a teacher allegedly dealt with a student, or personal problems a member of staff has in his or her work, is also a confidential matter unless someone is at risk, and even then has to be handled respectfully and with acknowledgement of what systems there are in the school for responding to such matters. In work with a group of staff in a seminar or conference, for example, the psychiatrist should be vigilant that high levels of emotion or misunderstanding of the purpose of the meeting does not lead a staff member into saying something inappropriate about themselves or someone else.

Deciding who needs to know any information gathered is not easy when other people are involved and share responsibility, but the problem is more manageable if it is treated for what it is: an important and interesting subject, legally and ethically, and directly relevant to child care, rather than as a peripheral and troublesome concern. The following points may be helpful.

First, the official age of consent to treatment (which includes the right to confidentiality about treatment) is 16 years, but it is a legal and ethical requirement that the young person's capacity to understand and take responsibility is also taken into account by the clinician. Thus there are 'grey areas' in which an older child may be regarded as unwise and at risk, or a younger child may be able to take an appropriate degree of responsibility. This may not make decisions about confidentiality easy, but the clinician should remember that everyone, including the courts, recognizes the difficulty, and respects decisions made 'on balance' and in the best interests of the child. The Gillick principle, named after a series of court rulings, offers the guidance that a young person may seek and use confidential counselling without parental consent provided that he or she is of sufficient understanding and intelligence, these being taken into consideration when thinking about the place of parental authority.(!1)

Second, it is important to be careful about confidential matters concerning people other than the patient. Thus it is not acceptable to refer, for example, to supposed difficulties in a marital relationship, without permission to do so from both parties.

Third, the clinician should provide privacy and discretion even when there is no 'heavy' issue of confidentiality. Sometimes handling the former sensitively resolves an impasse by dealing directly with a young person's anxiety, shame, and lack of trust, so that a negotiated agreement is possible about what will remain private to the sessions (e.g. sexual fears and fantasies) and what can be discussed with identified others (e.g. sexual misconduct).

Not everything has to be discussed with everybody. Thus, a head teacher or college principal may be perfectly happy simply to know that a pupil or student is being treated, and that the form master or tutor, with the pupil's knowledge, is being kept up to date with progress.

Finally, staff confidentiality, and indeed the reputation of the school, must be respected.

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